Rileigh Johnson-WVU Dietetic Intern

Documenting Experiences of a Dietetic Intern Through the Inaugural WVU ISPP Class

Adult Failure to Thrive (FTT) May 22, 2013

Filed under: Uncategorized — rileighjohnsonwvudietetics12 @ 10:22 pm

Adult failure to thrive is described as a “state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments” (Robertson, aafp.org).

Effects of adult FTT include: poor nutrition; decreased appetite; weight loss; and inactivity.

There are four syndromes that are prevalent in adults with FTT which are: impaired physical function; malnutrition; cognitive impairment; and depression.

There are many assessments, nutrition included, that need to be completed when an adult is diagnosed with FTT.  Medications should also be assessed to make sure they are not contributing to FTT.

Easily attainable goals should be care planned to maintain or improve overall functional status.

This diagnosis should prompt the physician to begin discussing end-of-life care.

In elderly patients, malnutrition is usually identified through hypocholesterolemia and hypo-albuminemia.

An RD assesses the patient for malnutrition which looks at availability of food, dietary intake, and caloric intake. Weight trend, current weight, and muscle wasting as evidenced by laboratory data are also assessed.

 

Urinary Urea Nitrogen (UUN) and Nitrogen Balance May 21, 2013

Filed under: Uncategorized — rileighjohnsonwvudietetics12 @ 10:31 pm

Urinary Urea Nitrogen (UUN) laboratory test is used to determine a patient’s nitrogen balance.

A positive nitrogen balance means that the body is metabolizing a sufficient amount of protein; which is why nitrogen is excreted through the urine.

A negative nitrogen balance (UUN <0) means that the body needs a higher protein intake.

When a UUN test is assessed, the RD will conduct a protein intake assessment where they will have the RN record food intake for 24 hours.

After this test period, the UUN is taken. A normal urinary nitrogen ranges between 6 and 17g in that 24 hour period.

The RD will make protein adjustments to that patient’s diet based on these results.

 

Don’t Fry Day May 20, 2013

Filed under: Uncategorized — rileighjohnsonwvudietetics12 @ 11:09 am

“Don’t Fry Day” is Friday May 24th, 2013. This day was created by the American Cancer Society for skin cancer awareness.

Non-melanoma skin cancer is the most common of all cancer types.

3,500,000 Americans have been diagnosed with skin cancer this year, followed by prostate cancer (238,590), breast cancer (234,580), lung cancer (228,190), and colorectal cancer (142,820).

The sun’s UVA and UVB rays cause most skin cancers. These harmful rays can cause DNA damage which increases the risk of skin cancer. UVA and UVB rays can cause dark patches, wrinkles, loose skin, premature aging, sunburns, DNA damage, and eye problems.

Anyone can get skin cancer!

Be extremely careful though if you have any of the following:

-natural blonde or red hair

-have freckles

-have fair skin

-have had skin cancer before

-live in or travel to hot climates or high altitudes

-take medications that make you sensitive to light (ask your pharmacist or physician)

-have had a lot of sunburns or burn before tanning

-have a condition that lowers your immune system

-have a family history of skin cancer, especially melanoma

-have a lot of moles, or large or irregularly shaped moles

Protect yourself!!!

Sunscreen 101:

– Broad spectrum suncreen: protects against UVA and UVB rays

– SPF of 30 or greater (protects 97% of UVB rays)

– Water resistant (40 minutes of total protection)

How to apply it:

    – 1 ounce (a palmful) should be used to cover arms, legs, face, and neck. Be generous!

    – Don’t forget your hands, feet, ears, and underarms!

    – Reapply at least every 2 hours, sooner if you are in/out of  the water or sweating.

Reminders:

* Seek shade from 10am-4pm

* Ditch tanning beds or lamps

* Wear a hat

* Wear sunglasses

* Cover up with clothing

* Don’t forget to protect the kids!

Be sure to check out www.cancer.org for more great information on protecting you and your family against cancer!

 

 

New Admissions May 17, 2013

Filed under: Uncategorized — rileighjohnsonwvudietetics12 @ 9:44 pm

Before a resident is admitted to Genesis, whichever insurance they are under has to approve their stay.  Typically medicare covers the resident’s first 20 days.  After 20 days (depending on their second form of insurance) the resident is required to pay a co-pay by their second form of insurance, after 30 days, the resident is responsible for paying full price for their stay at Genesis.  Every insurance is different and not all residents have medicare.

Once the resident is admitted, the CDM will meet with the resident and discuss the food that is offered at the center.  The CDM will also ask the resident what their likes/dislikes are, if they would like to eat in the dining room, and beverages they would like at each meal.

The staff introduces themselves individually to the resident and then there will be a new admission meeting shortly after the resident is admitted.  The new admission meetings include: DON (director of nursing), social services, administrator, therapy, dietary, the billing department, and any family or friends the resident has that would like to attend.

A new resident will usually hit the nutrition UDA list 5-7 days after they are admitted.  If there are immediate nutritional concerns then the RD will assess them sooner.  Once the RD assesses them, they will then follow up if needed with that resident as often as necessary.

 

Nutrition Care Process (NCP) for Complex Diseases May 15, 2013

Filed under: Uncategorized — rileighjohnsonwvudietetics12 @ 9:28 pm

Determining the nutrition care process for each patient varies and really comes down to if the disease is acute or chronic, or if the disease is occurring at present or if there is a history of the disease.

Renal disease has different stages and requires different nutrition interventions that depend on how severe that individual’s CKD is and also if they are on dialysis.  Dialysis patients will typically have weight fluctuations, fluid restrictions, protein restrictions, and potassium restrictions.  Not all dialysis will have these restrictions it just again, depends on the stage of CKD that individual has.  Dehydration is a concern with patients on fluid restrictions. Meeting protein needs with patients on protein restrictions is also a concern.

Patients with CHF (congestive heart failure) are at risk for fluid overload and are sometimes placed on fluid restrictions, which poses a risk for dehydration.

Sepsis, includes UTI’s, has risks associated with skin breakdown, inadequate fluid intake, dehydration, and altered mental status.

Patients who have hepatic disease will often have fat intake limited; ammonia levels checked; checking for encephalopathy to see if lowering protein intake is necessary (often switching to milk proteins is better tolerated than meat proteins); if a patient has cirrhosis, an RD would recommend to increase protein intake.

Cancer patients are at risk for many different nutrition risks.  Inadequate oral intake (due to nausea, vomiting), malnutrition, and increased nutritional needs.

Each patient’s disease state is different and calls for specific nutrition interventions.

 

Total Parenteral Nutrition (TPN) May 13, 2013

Filed under: Uncategorized — rileighjohnsonwvudietetics12 @ 5:28 pm

Total Parenteral Nutrition (TPN) is administered intravenously for patients who:

        – Do not have a functioning GI tract

        – Who have disorders requiring complete bowel rest such as:

                 *Some stage of ulcerative colitis

                 *Bowel obstruction

                 *Certain pediatric GI disorders

                 *Short bowel syndrome due to surgery

A needle or catheter is placed in the patient’s vein for 10-12 hours once a day or 5 times a week.

Includes a combination of sugar and carbohydrates, proteins, lipids, electrolytes, and trace elements (Solution will contain all or some of these nutrients depending on the patient). Electrolytes include: sodium, potassium, chloride, phosphate, calcium, and magnesium.  Trace elements include: zinc, copper, manganese, and chromium. Since this is a concentrated solution it can cause thrombosis of peripheral veins, a central venous catheter is usually required.

Solutions will again vary by patient, age, and disorder.

Renal insufficiency patients that are not being treated for liver failure or dialysis the solution would be a reduced protein solution and high essential amino acid content.

Patients with heart or kidney failure would require a lower volume intake.

Neonates would require a lower dextrose concentration (17-18%)

Patients with respiratory failure would require a lipid emulsion which provides most nonprotein calories to minimize carbon dioxide production by carbohydrate metabolism.

Complications from TPN include:

-Glucose abnormalities

-Abnormalities of serum electrolytes and minerals

-Hepatic complications

-Volume overload

-Gallbladder complications

-Adverse reactions to lipid emulsions

-Metabolic bone disease

** Only about 5-10% of patients experience complications.

Side Effects: mouth sores; poor night vision; skin changes.

Less common side effects: fever or chills; stomach pain; difficulty breathing; rapid weight gain/loss; increased urination; upset stomach; vomiting; confusion/memory loss; muscle weakness, twiching, or cramps; swelling of the hands, feet, or legs; thirst; fatigue; changes in heart beat; tingling in the hands or feet.

 

In-Service at Genesis May 10, 2013

Filed under: Uncategorized — rileighjohnsonwvudietetics12 @ 2:33 pm

Every 5 years Genesis adopts a new diet manual.  This year, the centers adopted the Becky Dorner and Associates Diet Manual.  The new diets went into effect on May 7, 2013. March of 2013, Diana and I listened to a webinar for the new diet manual.  The regional managers had this webinar for RD’s, CDM’s, and Speech therapists. 

My in-service assignment was to present the new diet manual information to RN’s, CNA’s, housekeeping, activities, and any other staff member who is involved in the dining room.  The in-service is mandatory and will be held 4 different times through out the week for each center.  Tygart Center is Monday May 6, 2013 and Wednesday May 8, 2013 from 7am-7:20 am and 3pm-3:20 pm.  Pierpont Center’s in-services are Tuesday May 7,2013 and Thursday May 9,2013 from 7am-7:20am and 3pm-3:20pm. 

Each in-service began by explaining that CMS (centers for medicare and medicaid services) supports the new diet manual.  The new diet manual is recommending as close to a regular diet as possible for each resident.  Research presented revealed little benefit to many older individuals with chronic conditions from restrictions in dietary sugar and sodium, as well as little benefit from tube feedings, pureed diets, and thickened liquids.  The new standards recommend to clinicians and prescribers that a regular diet become the default with only a small number of individuals needing restrictions.  Again, Genesis adopted the Becky Dorner and Associates Diet Manual which is available on the Genesis website and hard copies are also available in the dietary office. 

The following diets are available on the standard menu:

– Regular/ Liberalized

– Dysphagia Advanced

– Dysphagia Puree

– Consistent Carbohydrate

– No Added Salt

– 2 gram Sodium

– Heart Healthy

– Liberal Renal

– Gluten Free

The following diets are the House Diets (which will be used first and if there are any restrictions that need to be made, the physician will adjust accordingly):

– Regular/ Liberalized

– Regular/ Liberalized w/ sugar substitute

– Regular/ Liberalized, No Salt pack

– Dysphagia Advanced w/ chopped meats

– Dysphagia Puree

Research indicates that meal intake improves when diet are as near “normal” as possible. In keeping with this philosophy, Genesis encourages liberalization of more restrictive diets when clinically appropriate.

The regular/ liberalized, no salt pack is the same as the previous NAS (no added salt) diet from the old diet manual.  The new diet manual’s No Added Salt is more restrictive.

Dysphagia advanced w/ chopped meats combines the previous diet manual’s mechanical soft and advanced mechanical soft diets.  The speech therapists have been working with each resident to determine if this needs to be tweaked.

The regular/liberalized diet provides an average of 2500 kcal/day and 87 grams of protein/ day.  This is intended for individuals with no dietary restrictions.  Small portions and large portions can also be prescribed.  If a resident is 78 inches tall for example, they require over 2500 kcal/day, large portions will usually be prescribed so that this resident meets their estimated nutritional needs. 

Regular/ liberalized with sugar substitute is intended for individuals with diabetes, or on a weight control plan.  Highly concentrated sugars such as regular sugar and soda are not allowed and dietetic products are substituted.  Diet hot chocolate, diet gingerale, and diet syrup are available upon resident request.

Regular/liberalized , no salt pack is intended for individuals requiring a mild sodium restriction.  This is the regular/liberalized diet but a salt packet will not be provided at meals.  If a staff member sees a resident using salt at meals or is requesting salt, let the charge nurse or RD know so that adjustments can be made.  You may also educate the resident on why they are not provided a salt pack but you can not not allow the resident to use salt if they are requesting it.

Dysphagia Advanced w/ Chopped Meats is intended for individuals with mild chewing or swallowing difficulty.  Meat is chopped or flaked and moistened.  Chopped meat is the size of a pea.  Vegetables and fruit are the size of a pea.  Previously, fresh fruit was not allowed on this diet, if dietary can chop it to the size of a pea, it will be served.  Vegetables (whole, chopped, mashed, cooked) are allowed; finely chop fresh onions and tomatoes are also allowed.  Toast and grilled sandwiches were not allowed on the previous diet manual.  They are allowed with the new diet manual except the crust is removed by dietary. 

Dysphagia Puree is intended for individuals unable to chew and/or significantly impaired tongue or jaw movement.  This diet is the same as the previous pureed diet except that all foods are allowed if they can puree it smooth.  Items such as pizza and fresh fruit will be served pureed smooth. This diet provides an average of 2600 kcal/day and 90 grams of protein.

If any intolerances are observed, inform ST, charge nurse, physician immediately. 

A diet conversion chart was created to be placed at each nursing unit so that when a new admission arrives, the charge nurse can easily change the hospital diet to the house diet that coincides with it.

Admission Diet Order–> Suggested House Diet Order:

-Regular Diet, General Diet, Low Cholesterol and/or Low Fat Diet, Bland diet, lactose free or lactose intolerant diet, low residue diet, or GERD diet will be changed to regular/liberalized diet.  ** Dietary will identify any allergies or specific food intolerances on the resident tray card

-ADA diet, 1500, 1800, 2000 etc calorie ADA diet, no concentrated sweets diet (NCS), no added sugar diet, carbohydrate controlled diet, consistent carbohydrate diet–> regular/liberalized with sugar substitute.

-No added salt (NAS) diet, Heart Healthy Diet (HHD), Cardiac Diet, Low sodium diet, 4 gram sodium diet, and 2 or 3 gram sodium diet–> Regular/liberalized, no salt pack.  ** RD will assess and make any further recommended changes as indicated.

-Renal Diet and Dialysis Renal Diet–> Regular/liberalized, no salt pack, no orange juice, omit banana at breakfast. ** RD will assess and make any further recommended changes as indicated.

-Low Potassium Diet and 2-3 gram Potassium Diet –> Regular/liberalized, no orange juice, omit banana at breakfast.

-Regular with chopped meats and regular with ground meats–> Regular/Liberalized with chopped meats.

-Dysphagia Diet Levels II and III, Advanced dysphagia diet, Dysphagia mechanical diet, Soft or mechanical soft diet–> Dysphagia Advanced with chopped meats.

-Dysphagia Diet level I, Dysphagia pureed diet, pureed diet–>Dysphagia Puree.

-Oral Supplements: Ensure, Glucerna, Boost –> House Supplement.

** Please specify QD, BID, or TID. These will be sent between meals.

Finally I discussed the new diet order and communication form.  LPN/RN on admit order, omnicare MD admit order form will not have new diets at this time, they will have to physically write these out.  Example: if the resident is a regular/liberalized diet, no salt pack, the LPN/RN will check regular/liberalized on the form and write in the other section: no salt pack.

Diana created a quiz to make sure that each staff member understood the new diet manual.

Overall, I think that the in-services went well and that the staff understood the new diets.  Diana lamenated copies of the conversion chart for each nurse’s station.  Staff is encouraged to ask the RD for help if need be.

 

 
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